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Download and complete this form to end your premium Part A, Part B, or Part B immunosuppressive drug coverage. Learn about the consequences, requirements, and how to re-enroll in Medicare if needed.
31 sty 2022 · CMS 1763. Form Title. Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance. Revision Date. 2022-01-31. O.M.B. #. 0938-0025. O.M.B. Expiration Date. 2024-04-30.
Najlepiej jest zgłosić polskie świadczenie wysyłając do nas wypełniony druk SSA-308 (PDF 618 KB) wraz z kopią decyzji z ZUS lub KRUS. Można też poinformować nas listownie podając fakty i swoje dane kontaktowe (zwłaszcza aktualny numer telefonu) i załączyć kopię decyzji o przyznaniu polskich świadczeń.
If you are enrolled in Medicare and wish to voluntarily stop your Medicare coverage, complete a CMS-1763 Form. This form was released by the U.S. Department of Health and Human Services. You can download a fillable Form CMS 1763 through the link below.
The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and 1818A(c)(2)(B) of the Social Security Act require filing of notice advising the Administration when termination of Medicare coverage is requested.
Fill out Request for Termination of Premium Hospital Insurance of Supplementary Medical Insurance (Form CMS-1763) (PDF) and fax or mail it to your local Social Security office. You can cancel Part A only if you pay a premium for it.
1 sty 2006 · CMS Forms List. The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title. Showing 1 – 10 of 167 entries.
